Laserfiche WebLink
SWRCB,January 2006 <br /> Spill Bucket Testing Report Form JUN 0 8 2016 <br /> This form is intended for use by contractors performing annual testing of UST spill containment ssgwwcompleted form and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submiltta-tczth aalregulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name: Circle K Date of Testing: 05-17-16 <br /> Facility Address: 419 SOUTH MAIN STREET MANTECA CALIFORNIA 95366 <br /> Facility Contact: BOBBY Phone: 209-239-7978 <br /> Date Local Agency Was Notified of Testing:04-25-16 <br /> Name of Local A;ency Inspector 01'presew during testing): SAN JOAQUIN CO ELANA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: AFFORDA TEST 416 2°" Street Galt,CA 95632 (209) 744-0112 Fax: (209) 744-0116 <br /> Technician Conducting Test: ❑ Lyle D.Nimmo ❑ Zane A.Nimmo ❑ David A.Winkler ® Felix G.Ramirez <br /> 5249115-UT 5263322-UT 5263373-UT 5273934-UT <br /> Credentials': ®ICC Service Tech. ®SWRCB Tank Tester <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ®Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: TAPE/H2O Equipment Resolution: 1'16 <br /> Identify Spill Bucket(/3t 7unk 1 87 2 91 3 DIE 4 <br /> un/her, Stored Product etc.) <br /> ®Direct Bury ®Direct Bury ® Direct Bury ❑Direct Bury <br /> Bucket Installation Type: L]Contained in E]Contained in <br /> El Contained in Sump El Contained in Sump Sump Sum <br /> Bucket Diameter: I 1 11 1 1 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying _ - - <br /> vacuum/water and start of test: <br /> Test Start Time(Tj): 1230 1230 1230 <br /> Initial Reading(Rt): 13 1/2 13 13 1/2 <br /> Test End Time(TF): 1430 1430 1430 <br /> Final Reading(RF): 13 1/3 13 13 1/2 <br /> Test Duration(TF—T,): 1 HOUR 1 HOUR I HOUR <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or <br /> C riteria: <br /> Test Result: ® Pass ❑Fail ® Pass ❑Fail ® Pass ❑Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> PHIL TITE BUCKETS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information contained in this report is true,accurate,and in full compliance�8 ith legal requirements. <br /> er <br /> Technician's Signature: Date:05-17-16 <br /> ' State laws and regulations do not currently require testing to be performed by a qualified contractor.However,local requirements <br /> may be more stringent. <br />